Medical Manuscript
Identifying Patients in the Acute Psychiatric Hospital Who May Benefit From a Palliative Care Approach
American Journal of Hospice & Palliative Medicine® 1-5 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114554795 ajhpm.sagepub.com
M. Caroline Burton, MD1, Mark Warren, MD2, Stephen S. Cha, MS3, Maria Stevens, BA4, Megan Blommer, BA5, Simon Kung, MD2, and Maria I. Lapid, MD2
Abstract Identifying patients who will benefit from a palliative care approach is the first critical step in integrating palliative with curative therapy. Criteria are established that identify hospitalized medical patients who are near end of life, yet there are no criteria with respect to hospitalized patients with psychiatric disorders. The records of 276 consecutive patients admitted to a dedicated inpatient psychiatric unit were reviewed to identify prognostic criteria predictive of mortality. Mortality predictors were 2 or more admissions in the past year (P ¼ .0114) and older age (P ¼ .0006). Twenty-two percent of patients met National Hospice and Palliative Care Organization noncancer criteria for dementia. Palliative care intervention should be considered when treating inpatients with psychiatric disorders, especially older patients who have a previous hospitalization or history of dementia. Keywords hospital medicine, prognosis, palliative medicine, dementia, mortality, hospice
Introduction There is an increasing recognition of the need to improve the quality of end-of-life care. In 2008, only 38.5% of all deaths in the United States were under the care of a hospice program,1 of which 83.2% of patients were 65 years or older, more than one-third were 85 years or older, and with the pediatric and young adult population accounting for less than 1% of hospice admissions. When hospice care was established in the United States in the 1970s, patients with cancer made up the largest percentage of hospice admissions. Today, there are more noncancer (58.7%) diagnoses for patients on hospice, and in 2008, the top 4 noncancer diagnoses among hospice patients showed a continued trend of less cancer diagnoses (debility unspecified 15.3%, heart disease 11.7%, dementia 11.1%, and lung disease 7.9%).1 Hospice care not only improves the quality of life of patients and families but also reduces medical costs.2 It is unknown what percentage of these patients received palliative care prior to hospice enrollment. There is considerable suffering that occurs for many patients in their last days to months of life in the context of frequent hospitalizations and extensive medical utilization.3,4 Palliative care is frequently only offered late in the course of the disease and only after curative measures have been exhausted. Although 90% of Americans prefer to die at home,5 60% to 80% actually die in institutional settings,6,7 often in the context of invasive procedures, artificial support
of basic human functions (eg, nutrition and ventilation), or resuscitation efforts. Hospitalization signals a high-acuity event in an individual’s medical condition and presents an opportunity to improve the quality of end-of-life care by identifying those who will benefit from a palliative care approach. Identifying the appropriate patients, addressing cognitive care issues earlier in the course of illness, and initiating an ongoing dialogue may be the first critical step in preparing persons for the end of life and integrating palliative with curative treatment. The CARING criteria are a set of prognostic criteria that have been proposed to identify persons near the end of life upon hospital admission.8 The 5 indicators include Cancer as the primary diagnosis, Admissions equal or more than 2 in the past year,
1
Department of Medicine, Mayo Clinic, Jacksonville, FL, USA Department of Psychiatry, Mayo Clinic, Rochester, MN, USA 3 Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA 4 Minnesota State University, Mankato Undergraduate University, Mankato, MN, USA 5 University of St. Thomas, St. Paul, MN, USA 2
Corresponding Author: M. Caroline Burton, MD, Department of Medicine, Mayo Clinic, 4500 San Pablo Drive, Jacksonville, FL 32224, USA. Email: [email protected]
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American Journal of Hospice & Palliative Medicine®
2 Residence in a nursing home, Intensive care unit admission with multiorgan failure, and 2 or more Noncancer hospice Guidelines.9 The tool was designed and validated in a Veteran’s administration patient population admitted to general medical wards or the medical intensive care unit (ICU).8 The tool was recently validated in a broader patient population of medical and surgical patients in a university and safety-net hospital setting.10 Just as with acute care hospitalization, psychiatric hospitalization is an opportunity for health care providers to discuss health care goals including end-of-life care and palliative intervention with patients, their families, and other care givers. To our knowledge, no study has identified prognostic criteria predictive of mortality for adults admitted to an inpatient psychiatric unit. Our objective was to examine the validity of the CARING criteria in this patient population.
Methods The Mayo Clinic institutional review board approved this study. The study setting is an academic tertiary care referral center in the upper Midwest. The institutional data warehouse, the Mayo Clinic Life Sciences System, was queried to identify unique patients admitted to an inpatient psychiatric service during a 12-month period in 2008. The patients with psychiatric disorders included in the study were admitted to a dedicated medical psychiatric service with a census of 14 patients consisting of 7 patients aged 65 years and older and 7 patients who met either of the following requirements: age 18 years or greater with active medical illness or age 50 to 64 years without medical illness. For patients with multiple admissions, only the index hospitalization was used for data collection. Only records with prior research authorization were reviewed. Data manually extracted from the medical records included demographic information, CARING prognostic criteria including National Hospice and Palliative Care Organization (NHPCO) noncancer hospice guidelines and ICU admission with multiorgan failure (Appendix A), and mortality within 1-year of index hospitalization. Death was determined from review of clinic registration database. Records that did not indicate a date of death were reviewed to determine whether a follow-up appointment had occurred beyond the 1-year end point.
Data Analysis The primary end point was mortality status or death. Published CARING prognostic criteria scoring guidelines were used.8 Scores were categorized into high, medium, and low-risk groups for 1-year mortality based on the original CARING criteria analysis: cancer, 10 points; admissions (>2), 3 points; residence in a nursing home, 3 points; ICU with multiple organ failure, 10 points; and NHPCO noncancer hospice guidelines, 12 points. Quartiles were then established according to age with assigned points, 75, 3 points. Demographic and clinical data were summarized with mean, percentages, and frequency.
Table 1. Demographic and Clinical Information and Caring Criteria Scoring of Study Population. Variable Age, yrs Age, n (%) 2) noncancer guidelines, n (%) Risk, n (%) Low Medium High
Patients, N ¼ 276 68.04 + 21.42 37 37 87 115 9.97
(13) (13) (32) (42)
102 (37) 174 (63) 55 (20) 0 57 (21) 95 (34) 0 0 2 (1) 0 1 61 (22) 0 1 0 0 181 (66) 95 (34) 0
Abbreviations: LOS, length of stay; ICU, intensive care unit; NHPCO, National Hospice and Palliative Care Organization; CVA, cerebrovascular accident; CARING, Cancer, Admitted to the hospital for 2 times, Resident in a nursing home, ICU admission with multiorgan failure, and Noncancer hospice Guidelines.
Multiple logistic regression models were used to determine predictors of mortality.
Results Two hundred and seventy-six patients were admitted to the inpatient psychiatric service. We were unable to determine date of death or confirm a follow-up appointment after 1 year of index hospitalization for 4 (1.4 %) patients. Demographic and clinical information are shown in Table 1. Fifty-five (20%) patients died within 1 year of index hospitalization. There were no patients with admitting diagnosis of cancer. With respect to NHPCO noncancer guidelines, 61 (22%) patients met the criteria for dementia followed less commonly by cardiac disease, HIV/AIDS, and stroke/cerebrovascular accident (Table 1). Of the 61 patients with dementia, 2 (3.5%) patients died during hospitalization, and 24 (42%) patients died within 1 year of hospitalization. When stratified into low, medium, or high risk based on weights assigned to each CARING prognostic
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Table 2. Logistic Model to Predict 1-Year Mortality. Variable Admissions 2 or more in past year Residence in nursing home Age
Estimate
Odds ratio (95% CI)
P value
0.94
2.57 (1.24-5.35) .0114
0.57 0.67
1.77 (0.91-3.45) .0927 1.96 (1.34-2.88) .0006
Abbreviation: CI, confidence interval.
criteria, there were 66% in the low-risk group, 34% in the medium-risk group, and no patients in the high-risk group (Table 1). Predictors of 1-year mortality were 2 or more admissions in the past year (P ¼ .0114) and age (P ¼ .0006; Table 2). The other CARING prognostic items did not predict mortality.
Discussion Our study is the first to identify patients admitted to a psychiatric inpatient unit who may benefit from a palliative care approach. Of the CARING criteria, we found that greater than 2 psychiatric admissions in the previous year and older age were associated with 1-year mortality. The association of readmissions and mortality was demonstrated in the original CARING study with increased risk with advanced age.8 Although reflecting a trajectory of decline, frequent hospitalization can also serve as a source of considerable suffering through multiple transitions, changing surroundings, and fragmented care. In studies of nursing home residents, the burdens of hospitalization often outweigh the benefits.11 Just as with medical admissions, clinicians should consider palliative care consultation for patients with frequent psychiatric hospitalizations. The 1-year mortality rate was 20%, which underscores the need for palliative care discussions in patients with psychiatric disorders. There were no patients in this study who were admitted with a diagnosis of cancer. However, 22% of patients met the NHPCO noncancer guidelines for dementia. Previous work shows that elderly patients with dementia have increased mortality rates,12,13 and dementia is one of the top 4 noncancer hospice diagnoses. It is this subset of patients who may be particularly at risk. The important implication from this study is that care providers should consider palliative intervention with elderly adult patients who have had a psychiatric hospitalization in the past year and/or a history of dementia, to lessen needless suffering for the patient and the patient’s family. Palliative measures can be performed in conjunction with ongoing therapy, and hospitalization is an opportune time not only in medical patients but also in patients with psychiatric disorders for these discussions to occur. Too often health care providers first consider palliative intervention when all therapeutic measures have been exhausted. This study is not without limitation. It is a small study with an ethnically homogeneous patient population limiting the
external validity of its results. Because this is a retrospective study, data analyses are limited by the quality and accuracy of the data in the electronic medical record. We may underreport the medical comorbidity and the number of patients meeting NHPCO noncancer guidelines because this information perhaps was not obtained during a psychiatric hospitalization. Also, we did not collect information regarding psychiatric diagnoses on admission and therefore, we do not know the role psychiatric illness may play in mortality prognosis. It is also problematic applying the CARING criteria to a patient population with psychiatric disorders where cancer will almost never be the primary diagnosis; nevertheless, we believed such criteria to be a good place to start.
Conclusion With patients who carry a diagnosis of cancer, clinicians may tend to think palliative, but less so with respect to noncancer diseases including psychiatric disorders requiring inpatient treatment. Identification of patients who would benefit from a palliative care intervention is necessary to provide timely care not only for medical patients but also for patients with psychiatric disorders. We found that in adult patients admitted to an inpatient psychiatric unit, 2 or more hospitalizations during the previous year and advanced age were associated with increased 1-year mortality, and nearly half of the patients who died had dementia. These patients may be especially at risk, and palliative care consultation should be considered.
Appendix A. Caring Criteria CARING Criteria* The CARING criteria8,10 must be applied to patients who are hospitalized on the first day after admission-that is they met the criteria on the day of admission. It is unknown if the CARING criteria are predictive of high mortality when applied to patients who are either not in the hospital or later in the hospital stay. Cancer Is there a primary diagnosis of cancer? This includes patients who are admitted for chemotherapy (most chemo is administered as an outpatient, patients who require hospitalization for administration of chemo are likely more ill or have more aggressive cancers requiring more intensive monitoring), due to complications from their chemotherapy (ie, neutropenic fever), or for aggressive symptom management. What is important about this criterion is that cancer must be the primary reason they are admitted. A person with colon cancer admitted for suspected angina would not qualify. Admitted to the hospital for > two times in the past year for a chronic illness. For example, a man is admitted with pneumonia and COPD exacerbation and looking back at his chart you discover that he was also admitted for a COPD exacerbation two months ago. That would add up to two hospital admissions in the past year for a chronic illness therefore the patient would
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American Journal of Hospice & Palliative Medicine®
4 meet this criterion. A patient admitted twice in the past year for musculoskeletal chest pain would not meet the criterion. Resident in a nursing home. A patient admitted from either a long-term care facility or a skilled nursing facility would meet this criterion. It is essentially a proxy for poor functional status. ICU admission with multi-organ failure. An example would be a patient admitted to the ICU requiring mechanical ventilation (pulmonary system in failure) and on pressors or in renal failure (either requiring dialysis or nearing that point-a small increase in the creatinine would not qualify for organ failure). Non Cancer Hospice Guidelines-Patient must meet at least two items in any given category (see next page). *Included with permission from Youngwerth J, Min SJ, Statland B, Allyn R and Fischer S. Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med. 2013; 8: 696-701. Non Cancer Hospice criteria9
Appendix. (continued)
Renal
Dementia
Definitions of Multiple Organ Failure*þ
Stop/decline dialysis
Unable to ambulate independently Urinary or fecal incontinence Unable to speak with more than single words Unable to bathe independently
Not candidate for transplant Urine output < 40 cc/24 hours Creatinine > 8.0 (>6.0 for diabetics) Creatinine clearance 10 cc/min Uremia Persistent serum K þ > 7.0 Co-morbid conditions: Cancer CHF Chronic lung disease AIDS/HIV Sepsis
Unable to dress independently Co-morbid conditions: Aspiration pneumonia Pyelonephritis Decubitus ulcer Difficulty swallowing or refusal to eat
Hepatorenal syndrome Hepatic encephalopathy Spontaneous bacterial peritonitis Recurrent variceal bleed Co-morbid conditions as listed in Renal
Impaired sitting balance Karnofsky < 50% Recurrent aspiration Age > 70 Co-morbid conditions as listed in Renal
HIV/AIDS
Neuromuscular
Persistent decline in function Chronic diarrhea x 1 year
Diminished respiratory function Chosen not to receive BiPAP/ vent Difficulty swallowing Diminished functional status Incontinence Co-morbid conditions as listed in Renal
Decision to stop treatment CNS lymphoma MAC-untreated Systemic lymphoma Dilated cardiomyopathy CD4 < 25 with disease progression Viral load > 100,000
1.
2.
Cirrhosis
Cardiac
Pulmonary
Ejection fraction < 20% Symptomatic with diuretics and vasodilators Not candidate for transplant
Dyspnea at rest FEV1 < 30%
3.
History of syncope Systolic BP < 120 mm HG CVA cardiac origin Co-morbid conditions as listed in Renal
Frequent ER or hospital admits for pulmonary infections or respiratory distress Cor pulmonale or right heart failure O2 sat < 88% on O2 PCO2 > 50 Resting tachycardia > 100/min Comorbid conditions as listed in Renal
Liver
Stroke/CVA
End stage cirrhosis Not candidate for transplant Protime > 5 sec and albumin 3 days Limb paralysis Urinary/fecal incontinence
History of cardiac arrest
4.
5.
6.
(continued)
7.
Respiratory Failure (requiring mechanical ventilation counts) a. Respiratory rate 5 or 49 breaths/minute b. PaCO2 50 mm Hg c. AaDO2 350 mmHg (AaDO2 ¼ 713 FIO2 – PaCO2 – PaO2) d. Requires mechanical ventilatory support > 24 hours Cardiovascular Failure (requiring vasopressors counts) a. Heart rate 54 beats/minute b. Mean arterial pressure 49 mm Hg and/or systolic blood pressure, 60 mm Hg c. Ventricular tachycardia and/or ventricular fibrillation d. Serum pH 7.24 with a PaCO2 49 mm Hg Renal Failure (requiring new hemodialysis counts) a. Urine output 479 ml/24 hours or 159 ml/8 hours b. BUN 100 mg/dL c. Creatinine 3.5 mg/dL Hematologic Failure a. WBC 1000 mm3 b. Platelets 20,000 mm3 c. Hematocrit 20% or Hemoglobin 6.7 Neurologic Failure a. Glasgow Coma Score 6 (in absence of sedation at any one point in a day) Hepatic Failure a. Bilirubin 3 mg/dL b. INR > 1.5 c. AST > 2 times normal Gastrointestinal Failure a. GI bleed requiring transfusion of 2 units of blood
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*Please note that the ACCP/SCCM consensus guidelines for multiple organ dysfunction syndrome state that specific descriptors of this continuous process are not currently available. þ Used with permission from Knaus et al. Prognosis in acute organ system failure. Annal Surg. 1985;202 (6): 685-693.
4. 5.
Authors’ Note
6.
The data in this article were previously presented at the American Association for Geriatric Psychiatry Annual Meeting, March 16, 2013, in Los Angeles, California
7. 8.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 9.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
10.
References 1. Engleman P, Liebow AA, Gmelich J, Friedman PJ. Pulmonary hyalinizing granuloma. Am Rev Respir Dis. 1977;115(6): 997-1008. 2. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007;65(7):1466-1478. 3. Lynn J, Harrell F Jr, Cohn F, Wagner D, Connors AF Jr. Prognoses of seriously ill hospitalized patients on the days before
11.
12. 13.
death: implications for patient care and public policy. New Horiz. 1997;5(1):56-61. Lubitz J, Prihoda R. The use and costs of Medicare services in the last 2 years of life. Health Care Financ Rev. 1984;5(3):117-131. Seidlitz L, Duberstein PR, Cox C, Conwell Y. Attitudes of older people toward suicide and assisted suicide: an analysis of Gallup Poll findings. J Am Geriatr Soc. 1995;43(9):993-998. Lunney JR, Lynn J, Hogan C. Profiles of older medicare decedents. J Am Geriatr Soc. 2002;50(6):1108-1112. Hogan C, Ginsburg PB, Gabel JR. Tracking health care costs: inflation returns. Health Aff (Millwood). 2000;19(6):217-223. Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285-292. Medical guidelines for determining prognosis in selected non-cancer diseases. The National Hospice Organization. Hosp J. 1996;11(2):47-63. Youngwerth J, Min SJ, Statland B, Allyn R, Fischer S. Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med. 2013;8(12):696-701. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365(13):1212-1221. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. Ostbye T, Hill G, Steenhuis R. Mortality in elderly Canadians with and without dementia: a 5-year follow-up. Neurology. 1999;53(3):521-526.
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Identifying Patients in the Acute Psychiatric Hospital Who May Benefit From a Palliative Care Approach
American Journal of Hospice & Palliative Medicine® 1-5 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114554795 ajhpm.sagepub.com
M. Caroline Burton, MD1, Mark Warren, MD2, Stephen S. Cha, MS3, Maria Stevens, BA4, Megan Blommer, BA5, Simon Kung, MD2, and Maria I. Lapid, MD2
Abstract Identifying patients who will benefit from a palliative care approach is the first critical step in integrating palliative with curative therapy. Criteria are established that identify hospitalized medical patients who are near end of life, yet there are no criteria with respect to hospitalized patients with psychiatric disorders. The records of 276 consecutive patients admitted to a dedicated inpatient psychiatric unit were reviewed to identify prognostic criteria predictive of mortality. Mortality predictors were 2 or more admissions in the past year (P ¼ .0114) and older age (P ¼ .0006). Twenty-two percent of patients met National Hospice and Palliative Care Organization noncancer criteria for dementia. Palliative care intervention should be considered when treating inpatients with psychiatric disorders, especially older patients who have a previous hospitalization or history of dementia. Keywords hospital medicine, prognosis, palliative medicine, dementia, mortality, hospice
Introduction There is an increasing recognition of the need to improve the quality of end-of-life care. In 2008, only 38.5% of all deaths in the United States were under the care of a hospice program,1 of which 83.2% of patients were 65 years or older, more than one-third were 85 years or older, and with the pediatric and young adult population accounting for less than 1% of hospice admissions. When hospice care was established in the United States in the 1970s, patients with cancer made up the largest percentage of hospice admissions. Today, there are more noncancer (58.7%) diagnoses for patients on hospice, and in 2008, the top 4 noncancer diagnoses among hospice patients showed a continued trend of less cancer diagnoses (debility unspecified 15.3%, heart disease 11.7%, dementia 11.1%, and lung disease 7.9%).1 Hospice care not only improves the quality of life of patients and families but also reduces medical costs.2 It is unknown what percentage of these patients received palliative care prior to hospice enrollment. There is considerable suffering that occurs for many patients in their last days to months of life in the context of frequent hospitalizations and extensive medical utilization.3,4 Palliative care is frequently only offered late in the course of the disease and only after curative measures have been exhausted. Although 90% of Americans prefer to die at home,5 60% to 80% actually die in institutional settings,6,7 often in the context of invasive procedures, artificial support
of basic human functions (eg, nutrition and ventilation), or resuscitation efforts. Hospitalization signals a high-acuity event in an individual’s medical condition and presents an opportunity to improve the quality of end-of-life care by identifying those who will benefit from a palliative care approach. Identifying the appropriate patients, addressing cognitive care issues earlier in the course of illness, and initiating an ongoing dialogue may be the first critical step in preparing persons for the end of life and integrating palliative with curative treatment. The CARING criteria are a set of prognostic criteria that have been proposed to identify persons near the end of life upon hospital admission.8 The 5 indicators include Cancer as the primary diagnosis, Admissions equal or more than 2 in the past year,
1
Department of Medicine, Mayo Clinic, Jacksonville, FL, USA Department of Psychiatry, Mayo Clinic, Rochester, MN, USA 3 Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA 4 Minnesota State University, Mankato Undergraduate University, Mankato, MN, USA 5 University of St. Thomas, St. Paul, MN, USA 2
Corresponding Author: M. Caroline Burton, MD, Department of Medicine, Mayo Clinic, 4500 San Pablo Drive, Jacksonville, FL 32224, USA. Email: [email protected]
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2 Residence in a nursing home, Intensive care unit admission with multiorgan failure, and 2 or more Noncancer hospice Guidelines.9 The tool was designed and validated in a Veteran’s administration patient population admitted to general medical wards or the medical intensive care unit (ICU).8 The tool was recently validated in a broader patient population of medical and surgical patients in a university and safety-net hospital setting.10 Just as with acute care hospitalization, psychiatric hospitalization is an opportunity for health care providers to discuss health care goals including end-of-life care and palliative intervention with patients, their families, and other care givers. To our knowledge, no study has identified prognostic criteria predictive of mortality for adults admitted to an inpatient psychiatric unit. Our objective was to examine the validity of the CARING criteria in this patient population.
Methods The Mayo Clinic institutional review board approved this study. The study setting is an academic tertiary care referral center in the upper Midwest. The institutional data warehouse, the Mayo Clinic Life Sciences System, was queried to identify unique patients admitted to an inpatient psychiatric service during a 12-month period in 2008. The patients with psychiatric disorders included in the study were admitted to a dedicated medical psychiatric service with a census of 14 patients consisting of 7 patients aged 65 years and older and 7 patients who met either of the following requirements: age 18 years or greater with active medical illness or age 50 to 64 years without medical illness. For patients with multiple admissions, only the index hospitalization was used for data collection. Only records with prior research authorization were reviewed. Data manually extracted from the medical records included demographic information, CARING prognostic criteria including National Hospice and Palliative Care Organization (NHPCO) noncancer hospice guidelines and ICU admission with multiorgan failure (Appendix A), and mortality within 1-year of index hospitalization. Death was determined from review of clinic registration database. Records that did not indicate a date of death were reviewed to determine whether a follow-up appointment had occurred beyond the 1-year end point.
Data Analysis The primary end point was mortality status or death. Published CARING prognostic criteria scoring guidelines were used.8 Scores were categorized into high, medium, and low-risk groups for 1-year mortality based on the original CARING criteria analysis: cancer, 10 points; admissions (>2), 3 points; residence in a nursing home, 3 points; ICU with multiple organ failure, 10 points; and NHPCO noncancer hospice guidelines, 12 points. Quartiles were then established according to age with assigned points, 75, 3 points. Demographic and clinical data were summarized with mean, percentages, and frequency.
Table 1. Demographic and Clinical Information and Caring Criteria Scoring of Study Population. Variable Age, yrs Age, n (%) 2) noncancer guidelines, n (%) Risk, n (%) Low Medium High
Patients, N ¼ 276 68.04 + 21.42 37 37 87 115 9.97
(13) (13) (32) (42)
102 (37) 174 (63) 55 (20) 0 57 (21) 95 (34) 0 0 2 (1) 0 1 61 (22) 0 1 0 0 181 (66) 95 (34) 0
Abbreviations: LOS, length of stay; ICU, intensive care unit; NHPCO, National Hospice and Palliative Care Organization; CVA, cerebrovascular accident; CARING, Cancer, Admitted to the hospital for 2 times, Resident in a nursing home, ICU admission with multiorgan failure, and Noncancer hospice Guidelines.
Multiple logistic regression models were used to determine predictors of mortality.
Results Two hundred and seventy-six patients were admitted to the inpatient psychiatric service. We were unable to determine date of death or confirm a follow-up appointment after 1 year of index hospitalization for 4 (1.4 %) patients. Demographic and clinical information are shown in Table 1. Fifty-five (20%) patients died within 1 year of index hospitalization. There were no patients with admitting diagnosis of cancer. With respect to NHPCO noncancer guidelines, 61 (22%) patients met the criteria for dementia followed less commonly by cardiac disease, HIV/AIDS, and stroke/cerebrovascular accident (Table 1). Of the 61 patients with dementia, 2 (3.5%) patients died during hospitalization, and 24 (42%) patients died within 1 year of hospitalization. When stratified into low, medium, or high risk based on weights assigned to each CARING prognostic
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Burton et al
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Table 2. Logistic Model to Predict 1-Year Mortality. Variable Admissions 2 or more in past year Residence in nursing home Age
Estimate
Odds ratio (95% CI)
P value
0.94
2.57 (1.24-5.35) .0114
0.57 0.67
1.77 (0.91-3.45) .0927 1.96 (1.34-2.88) .0006
Abbreviation: CI, confidence interval.
criteria, there were 66% in the low-risk group, 34% in the medium-risk group, and no patients in the high-risk group (Table 1). Predictors of 1-year mortality were 2 or more admissions in the past year (P ¼ .0114) and age (P ¼ .0006; Table 2). The other CARING prognostic items did not predict mortality.
Discussion Our study is the first to identify patients admitted to a psychiatric inpatient unit who may benefit from a palliative care approach. Of the CARING criteria, we found that greater than 2 psychiatric admissions in the previous year and older age were associated with 1-year mortality. The association of readmissions and mortality was demonstrated in the original CARING study with increased risk with advanced age.8 Although reflecting a trajectory of decline, frequent hospitalization can also serve as a source of considerable suffering through multiple transitions, changing surroundings, and fragmented care. In studies of nursing home residents, the burdens of hospitalization often outweigh the benefits.11 Just as with medical admissions, clinicians should consider palliative care consultation for patients with frequent psychiatric hospitalizations. The 1-year mortality rate was 20%, which underscores the need for palliative care discussions in patients with psychiatric disorders. There were no patients in this study who were admitted with a diagnosis of cancer. However, 22% of patients met the NHPCO noncancer guidelines for dementia. Previous work shows that elderly patients with dementia have increased mortality rates,12,13 and dementia is one of the top 4 noncancer hospice diagnoses. It is this subset of patients who may be particularly at risk. The important implication from this study is that care providers should consider palliative intervention with elderly adult patients who have had a psychiatric hospitalization in the past year and/or a history of dementia, to lessen needless suffering for the patient and the patient’s family. Palliative measures can be performed in conjunction with ongoing therapy, and hospitalization is an opportune time not only in medical patients but also in patients with psychiatric disorders for these discussions to occur. Too often health care providers first consider palliative intervention when all therapeutic measures have been exhausted. This study is not without limitation. It is a small study with an ethnically homogeneous patient population limiting the
external validity of its results. Because this is a retrospective study, data analyses are limited by the quality and accuracy of the data in the electronic medical record. We may underreport the medical comorbidity and the number of patients meeting NHPCO noncancer guidelines because this information perhaps was not obtained during a psychiatric hospitalization. Also, we did not collect information regarding psychiatric diagnoses on admission and therefore, we do not know the role psychiatric illness may play in mortality prognosis. It is also problematic applying the CARING criteria to a patient population with psychiatric disorders where cancer will almost never be the primary diagnosis; nevertheless, we believed such criteria to be a good place to start.
Conclusion With patients who carry a diagnosis of cancer, clinicians may tend to think palliative, but less so with respect to noncancer diseases including psychiatric disorders requiring inpatient treatment. Identification of patients who would benefit from a palliative care intervention is necessary to provide timely care not only for medical patients but also for patients with psychiatric disorders. We found that in adult patients admitted to an inpatient psychiatric unit, 2 or more hospitalizations during the previous year and advanced age were associated with increased 1-year mortality, and nearly half of the patients who died had dementia. These patients may be especially at risk, and palliative care consultation should be considered.
Appendix A. Caring Criteria CARING Criteria* The CARING criteria8,10 must be applied to patients who are hospitalized on the first day after admission-that is they met the criteria on the day of admission. It is unknown if the CARING criteria are predictive of high mortality when applied to patients who are either not in the hospital or later in the hospital stay. Cancer Is there a primary diagnosis of cancer? This includes patients who are admitted for chemotherapy (most chemo is administered as an outpatient, patients who require hospitalization for administration of chemo are likely more ill or have more aggressive cancers requiring more intensive monitoring), due to complications from their chemotherapy (ie, neutropenic fever), or for aggressive symptom management. What is important about this criterion is that cancer must be the primary reason they are admitted. A person with colon cancer admitted for suspected angina would not qualify. Admitted to the hospital for > two times in the past year for a chronic illness. For example, a man is admitted with pneumonia and COPD exacerbation and looking back at his chart you discover that he was also admitted for a COPD exacerbation two months ago. That would add up to two hospital admissions in the past year for a chronic illness therefore the patient would
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American Journal of Hospice & Palliative Medicine®
4 meet this criterion. A patient admitted twice in the past year for musculoskeletal chest pain would not meet the criterion. Resident in a nursing home. A patient admitted from either a long-term care facility or a skilled nursing facility would meet this criterion. It is essentially a proxy for poor functional status. ICU admission with multi-organ failure. An example would be a patient admitted to the ICU requiring mechanical ventilation (pulmonary system in failure) and on pressors or in renal failure (either requiring dialysis or nearing that point-a small increase in the creatinine would not qualify for organ failure). Non Cancer Hospice Guidelines-Patient must meet at least two items in any given category (see next page). *Included with permission from Youngwerth J, Min SJ, Statland B, Allyn R and Fischer S. Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med. 2013; 8: 696-701. Non Cancer Hospice criteria9
Appendix. (continued)
Renal
Dementia
Definitions of Multiple Organ Failure*þ
Stop/decline dialysis
Unable to ambulate independently Urinary or fecal incontinence Unable to speak with more than single words Unable to bathe independently
Not candidate for transplant Urine output < 40 cc/24 hours Creatinine > 8.0 (>6.0 for diabetics) Creatinine clearance 10 cc/min Uremia Persistent serum K þ > 7.0 Co-morbid conditions: Cancer CHF Chronic lung disease AIDS/HIV Sepsis
Unable to dress independently Co-morbid conditions: Aspiration pneumonia Pyelonephritis Decubitus ulcer Difficulty swallowing or refusal to eat
Hepatorenal syndrome Hepatic encephalopathy Spontaneous bacterial peritonitis Recurrent variceal bleed Co-morbid conditions as listed in Renal
Impaired sitting balance Karnofsky < 50% Recurrent aspiration Age > 70 Co-morbid conditions as listed in Renal
HIV/AIDS
Neuromuscular
Persistent decline in function Chronic diarrhea x 1 year
Diminished respiratory function Chosen not to receive BiPAP/ vent Difficulty swallowing Diminished functional status Incontinence Co-morbid conditions as listed in Renal
Decision to stop treatment CNS lymphoma MAC-untreated Systemic lymphoma Dilated cardiomyopathy CD4 < 25 with disease progression Viral load > 100,000
1.
2.
Cirrhosis
Cardiac
Pulmonary
Ejection fraction < 20% Symptomatic with diuretics and vasodilators Not candidate for transplant
Dyspnea at rest FEV1 < 30%
3.
History of syncope Systolic BP < 120 mm HG CVA cardiac origin Co-morbid conditions as listed in Renal
Frequent ER or hospital admits for pulmonary infections or respiratory distress Cor pulmonale or right heart failure O2 sat < 88% on O2 PCO2 > 50 Resting tachycardia > 100/min Comorbid conditions as listed in Renal
Liver
Stroke/CVA
End stage cirrhosis Not candidate for transplant Protime > 5 sec and albumin 3 days Limb paralysis Urinary/fecal incontinence
History of cardiac arrest
4.
5.
6.
(continued)
7.
Respiratory Failure (requiring mechanical ventilation counts) a. Respiratory rate 5 or 49 breaths/minute b. PaCO2 50 mm Hg c. AaDO2 350 mmHg (AaDO2 ¼ 713 FIO2 – PaCO2 – PaO2) d. Requires mechanical ventilatory support > 24 hours Cardiovascular Failure (requiring vasopressors counts) a. Heart rate 54 beats/minute b. Mean arterial pressure 49 mm Hg and/or systolic blood pressure, 60 mm Hg c. Ventricular tachycardia and/or ventricular fibrillation d. Serum pH 7.24 with a PaCO2 49 mm Hg Renal Failure (requiring new hemodialysis counts) a. Urine output 479 ml/24 hours or 159 ml/8 hours b. BUN 100 mg/dL c. Creatinine 3.5 mg/dL Hematologic Failure a. WBC 1000 mm3 b. Platelets 20,000 mm3 c. Hematocrit 20% or Hemoglobin 6.7 Neurologic Failure a. Glasgow Coma Score 6 (in absence of sedation at any one point in a day) Hepatic Failure a. Bilirubin 3 mg/dL b. INR > 1.5 c. AST > 2 times normal Gastrointestinal Failure a. GI bleed requiring transfusion of 2 units of blood
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Burton et al
5
*Please note that the ACCP/SCCM consensus guidelines for multiple organ dysfunction syndrome state that specific descriptors of this continuous process are not currently available. þ Used with permission from Knaus et al. Prognosis in acute organ system failure. Annal Surg. 1985;202 (6): 685-693.
4. 5.
Authors’ Note
6.
The data in this article were previously presented at the American Association for Geriatric Psychiatry Annual Meeting, March 16, 2013, in Los Angeles, California
7. 8.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 9.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
10.
References 1. Engleman P, Liebow AA, Gmelich J, Friedman PJ. Pulmonary hyalinizing granuloma. Am Rev Respir Dis. 1977;115(6): 997-1008. 2. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007;65(7):1466-1478. 3. Lynn J, Harrell F Jr, Cohn F, Wagner D, Connors AF Jr. Prognoses of seriously ill hospitalized patients on the days before
11.
12. 13.
death: implications for patient care and public policy. New Horiz. 1997;5(1):56-61. Lubitz J, Prihoda R. The use and costs of Medicare services in the last 2 years of life. Health Care Financ Rev. 1984;5(3):117-131. Seidlitz L, Duberstein PR, Cox C, Conwell Y. Attitudes of older people toward suicide and assisted suicide: an analysis of Gallup Poll findings. J Am Geriatr Soc. 1995;43(9):993-998. Lunney JR, Lynn J, Hogan C. Profiles of older medicare decedents. J Am Geriatr Soc. 2002;50(6):1108-1112. Hogan C, Ginsburg PB, Gabel JR. Tracking health care costs: inflation returns. Health Aff (Millwood). 2000;19(6):217-223. Fischer SM, Gozansky WS, Sauaia A, Min SJ, Kutner JS, Kramer A. A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria. J Pain Symptom Manage. 2006;31(4):285-292. Medical guidelines for determining prognosis in selected non-cancer diseases. The National Hospice Organization. Hosp J. 1996;11(2):47-63. Youngwerth J, Min SJ, Statland B, Allyn R, Fischer S. Caring about prognosis: a validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med. 2013;8(12):696-701. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011;365(13):1212-1221. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538. Ostbye T, Hill G, Steenhuis R. Mortality in elderly Canadians with and without dementia: a 5-year follow-up. Neurology. 1999;53(3):521-526.
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